Sport Health Volume 39 Issue 2 - Concussion in Sport by Sports Medicine Australia

Sport

health VOLUME 39 ISSUE 2 2022

Concussion in Sport FEATURING • Sports Related Concussion: Focus on Female Athletes • The Concussion Crisis in Sport: A Sociological Perspective • Diagnosing Concussion

Contents REGULARS

02 From the Chair SMA Board Chair, Professor Gregory Kolt speaks about the 2021-2024 Strategic Plan and looks forward to the events and courses being run across the year.

From the CEO

Persistent Concussion Symptoms – Review of Current Evidence

CEO Jamie Crain looks back on what has been achieved in 2021 and what is to come for SMA in 2022!

In this feature, Katrina Williams Specialist Neurological FAC and Emma Warner - Titled Neurological APA, review the current evidence around persistent concussion and the factors that are involved.

FEATURES

18 The Concussion Crisis in Sport: A Sociological Perspective

Sport Related Concussion – Focus on Female Athletes

E-Conference Wrap-up

Shreya McLeod discusses the specificity around concussion in female athletes and understanding why women are more susceptible to concussion.

Opinions expressed throughout the magazine are the contributors’ own and do not necessarily reflect the views or policy of Sports Medicine Australia (SMA). Members and readers are advised that SMA cannot be held responsible for the accuracy of statements made in advertisements nor the quality of goods or services advertised. All materials copyright. On acceptance of an article for publication, copyright passes to the publisher.

VOLUME 39 • ISSUE 2 2022

We take a look back on the 2021 SMA e-Conference and the successes that came from the event.

Publisher Sports Medicine Australia Sports House 375 Albert Rd Albert Park VIC 3206 sma.org.au ISSN No. 1032-5662 PP No. 226480/00028

Dominic Malcom looks at concussion and the debates around it from a sociological viewpoint, and discusses the ‘Concussion Crisis in Sport.’

Copy Editors Jack Sullivan, Archie Veera and Jodie Tennant PR, Communications and Marketing Manager Cohen McElroy Design/Typesetting Perry Watson Design Cover photograph gettyimages/peterschreiber.media Content photographs www.gettyimages.com.au / author supplied

Volume 39 • Issue 2 • 2022

INTERVIEWS

24 A Decade of Providing Evidencebased Concussion Education: CATT – the Concussion Awareness Training Tool Professor Kate Turcotte and colleagues look back on the work that has been done developing and implementing the CATT and how this is affecting the way we treat concussion related injuries. Prof Kate Turcotte, Samantha Bruin & Dr Shelina Babul

35 5 Minutes with Professor Andrew Gardner Professor Andrew Gardner details his path to becoming one of the worlds top concussion specialists.

38 Sports Medicine Around the World: Hungary

36 People Who Shaped SMA: Kay Copeland SMA Deputy Chair of the Board Kay Copeland shares her involvement with SMA and how it all started.

29 Diagnosing Concussion Dr Fatima Nasrallah discusses her work diagnosing concussion using digital imaging and the research being done to further progress in this area.

41 Sports Trainer Highlight: Patrick Moase Patrick Moase explain his journey to becoming a SMA accredited sports trainer.

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FROM THE CHAIR

Strategically Positioning SMA for Success SMA BOARD CHAIR, PROFESSOR GREGORY KOLT SUMMARISES THE YEAR THAT WAS, EXCITING ACCOMPLISHMENTS AT SMA AND THE EFFECTS OF CONCUSSION IN SPORT.

elcome to the first edition of Sport Health for 2022.

The year that was 2021 began in a state of limbo with the pandemic becoming a part of our everyday lives. During the first half of the year, Australia was still dealing with significant travel restrictions, lockdowns, postponement and cancellation of sports events, and escalating health concerns due to COVID-19. Soon, vaccines were introduced, global sporting events were back (i.e., the 2020 Tokyo Summer Olympics) and community sport saw a turnaround. With the implementation of the phased vaccine program, Sports Medicine Australia released a Vaccine Position Statement. We were united with the Government in the fight against COVID-19 and moving towards the “new COVID-normal state of life”. Early in 2021, SMA held its first hybrid (face-to-face and livestream) professional development event series, the 2021 Eminent Speaker Series. We were thrilled to have a massive turnout and its success led to the commencement of the 2021/2022 SMA Event Series covering debates, panel discussions, research, networking, and sports medicine management.

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Adding to the psychological trauma of COVID-19, Australia’s representative sports saw rising concussion rates, especially amongst youngsters and women, with concussions comprising nearly 13% of the sports injuries in community football. In mid-2021, the SMA 2021-2024 Strategic Plan was launched, cementing SMA as the authority on sports medicine, sports science, and physical activity in the Region. A particular highlight of 2021 was our highly successful SMA e-Conference, run over two weekends in October – world class speakers, a highly engaged online audience from across the globe, a virtual trade display, and around 500 participants across 10 countries. The team worked tirelessly and successfully implemented the first for SMA. I take this opportunity to send special thanks to my colleagues on the Board of Directors who work hard throughout the year ensuring SMA is strategically positioned for success. My gratitude also goes to our CEO, Jamie Crain, and his hard-working team across Australia, and to our many volunteers across State Councils and other Committees.

In this issue of Sport Health, we focus on Concussion. There have been an increasing number of cases of sport-related concussions and head injuries in Australia, causing concern for the future implications such injuries have on athletes. Despite the physical and mental challenges to sport in 2021, we will continue to promote our courses and training opportunities into 2022 to ensure a pool of accredited trainers, coaches and mentors who will motivate our athletes and encourage more people to partake in community sport. I thank all our contributors for their informed views on concussion. I hope you have an enjoyable read and understand its effects amongst athletes pre-, during and post-concussion injuries. Professor Gregory Kolt

FROM THE CEO

Finalising Plans for our 2022 SMA Conference WE HAVE A RANGE OF EVENTS AND OPPORTUNITIES FOR OUR MEMBERS THIS YEAR, AND I LOOK FORWARD TO SEEING EVERYONE IN PERSON VERY SOON.

elcome to 2022!

As many of you know, last October the SMA team successfully launched our first ever SMA e-Conference! This meant, for the first time in SMA history, the Conference could be easily accessed by delegates from all around the world. We were thrilled to host almost 500 delegates from 10 countries including Australia, Ireland, Japan, Malaysia, Netherlands, New Zealand, Portugal, Singapore, UK, and USA across our jam-packed event. We were also excited to have introduced a dedicated showcase stream for Sports Trainers and Community Sport to accompany our usual streams. We are now finalising plans for our 2022 conference, which we hope will be face-to-face again, but either way we can all look forward to an amazing program built on the best on sports medicine knowledge across the nation and beyond. 2021 was a busy year – SMA launched a first-of-its-kind Eminent Speaker Series which was followed by the 2021/22 SMA Event Series. We also created an Extreme Heat Policy at the beginning of the year, as there was a need for updated evidence-based guidelines to provide sporting participants the tools and knowledge for safe participation

Concussion continues to be a major issue in many of our most popular sporting codes, and it is appropriate that it receives our focus and attention.

in extreme heat conditions, prevalent in many parts of Australia. The SMA Research Foundation continues its generous contribution to support young researchers conduct their post-graduate study in the multidisciplinary fields of sports medicine and lifestyle disease prevention. SMA recently teamed up with Strapit, who is now our exclusive tape partner. This three-year agreement will see Strapit provide us the highest quality products to support all our Safer Sport Courses for Sports Trainers in Australia. Strapit is also kindly

providing exclusive discounts on a range of products such as first-aid kits, resistance bands, stretchers, bags, compression, bandages and sports tape for SMA members. We are excited to announce that SMA is currently conducting 100+ Safer Sport courses between the months January-March 2022. Our internal team has worked tirelessly to bring the best opportunities for everyone to practice Sports Medicine safely in Australia. This issue of Sport Health will dive deep into Concussion and its longterm effects for sports participants. Concussion continues to be a major issue in many of our most popular sporting codes, and it is appropriate that it receives our focus and attention. I am delighted to see our contributors covering a range of concussion topics such as Concussion in Women, Concussion Safeguarding, Neuroimaging Research, and the Concussion Awareness Training Tool. All of these topics will contribute towards improving health outcomes in our community which is what we are about. We hope you enjoy this read to kickstart the new year. We have a range of events and opportunities for our members this year, and with Australia adjusting to a COVID-19 state of normal, I look forward to seeing you in person very soon! Jamie Crain jamie.crain@sma.org.au VOLUME 39 • ISSUE 2 2022

Sport Related Concussion

Focus on Female Athletes BY SHREYA MCLEOD

AUSTRALIA’S ELITE SPORTSWOMEN HAVE EXPERIENCED A PERIOD OF UNPRECEDENTED SUCCESS OVER THE PAST DECADE. CURRENTLY, OVER 600,000 AUSTRALIAN WOMEN ARE PLAYING A VERSION OF FOOTBALL IN THE FORM OF SOCCER, AUSTRALIAN RULES, RUGBY LEAGUE OR RUGBY UNION.

he rise in participation in contact and collision sports has led to a concomitant increase in injuries, such as sport related concussions (SRC). A concussion is defined as a transient brain injury, caused by a direct blow or an indirect force transmitted from the body to the head or face. Typically, SRC is considered a functional neurological disturbance rather than a structural injury, making it difficult to detect on routine brain imaging. Recognising when someone has sustained a concussion, removing the athlete from play, and carefully assessing recovery in a stepwise manner, are all critical elements prior

Photo: Pornpak Khunatorn/ iStock

FEATURE: SPORT REL ATED CONCUSSION: FOCUS ON FEMALE ATHLETES

to returning the athlete to play. At the professional level, several contact and collision sports have adopted sideline technology, allowing medical staff and independent spotters to identify potential concussive events. However, at the community level, it is a medical diagnosis that frequently relies on selfreported symptoms such as dizziness, confusion, unsteadiness, nausea, and headaches. Symptoms may present immediately or evolve over a period of time, usually within the first 24 hours. Symptoms Headache is the most commonly reported symptom following a concussion.

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FEATURE: SPORT REL ATED CONCUSSION: FOCUS ON FEMALE ATHLETES

Women rate headache, pressure in the head and emotional lability higher than men. Other symptoms may include dizziness, fatigue, memory loss, concentration difficulties, insomnia, neck pain, irritability, visual disturbances, and feeling in a fog. Within the general population, women are also up to five times more likely to suffer from migraine headaches and, therefore, clinicians should consider the headache presentations of female athletes and offer appropriate management. Depending on the type of headache a multifactorial approach involving sleep hygiene, diet, hydration, exercise and stress reduction may also be indicated. Risk factors Women tend to be more aware of their symptoms and are more likely to report them, however, under-reporting still exists. As with men, women may minimise their symptoms to avoid missing games or not consider their injuries serious enough to warrant further discussions with the medical team. Although the research on the length of recovery is mixed, there is overall support for women taking longer to recover than men, with an average of 6-20 days longer. Recent studies have shown that women are still symptomatic up to 28 days post-concussion compared to men. Both genders report symptoms such as headaches, mental fatigue, concentration difficulties and mood swings. Men, however, are more likely to report amnesia and disorientation as their main symptom while women tend to complain of drowsiness and sensitivity to light. Women may also perform worse on neurocognitive testing. Broshek 6

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Photo: PeopleImages/ iStock

Sport Related Concussion Focus on Female Athletes

et al. found that females reported 1.7 times more cognitive concerns such as difficulty concentration, compared to males. They also have a lengthier return to play trajectory.

Female athletes are more likely to sustain a concussion when compared with their age and sport-matched male counterparts.

Hypotheses for genderbased differences These gender-based differences are believed to be a result of a combination of factors. Physical factors such as shorter neck dimensions, smaller head mass and narrower neck girth result in reduced neck strength in women. This, in turn, predisposes women to greater head-neck acceleration during impacts. Researchers believe that women may have a lower biomechanical threshold for SRC than men, with peak linear accelerations up to 20g lower, and that the diagnosis of SRC is based on the frequency and magnitude of head impact exposure. Anatomically speaking, male brains have more grey matter than white matter, indicating more active neurons whereas female brains have more white matter, suggesting better communication between areas of the brain. Additionally, males tend to be single hemisphere dependent for most tasks whereas women are bi-hemisphere dependent. If a head injury temporarily disrupted the supply of glucose and oxygen to the brain, it would have a significant impact on recovery. Finally, varying levels of female sex hormones in a cycle could alter concussion risk. A study found that sustaining a concussion in the follicular phase (after menstruation, before ovulation) was less likely to lead to symptoms a month later, compared with the luteal phase (after ovulation, before menstruation) resulting in

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FEATURE: SPORT REL ATED CONCUSSION: FOCUS ON FEMALE ATHLETES

poorer outcomes. However, these effects may be negated when women take contraceptive pills, reducing the severity of concussion symptoms but not necessarily altering days to recovery. Despite these differences, women are an understudied population, with very few studies addressing these concerns, resulting in a lack of gender specific treatment guidelines. Repeated concussions and long-term risk Understanding exactly why women are more susceptible to concussion is necessary to reduce the potential risk associated with participation in contact and collision sports. Future research needs to investigate other longer-term consequences of concussion, with women playing beyond pregnancy and childbirth. There are concerns, for example, that head impacts can increase the risk of neurodegenerative diseases such as Alzheimer’s and chronic traumatic encephalopathy. In the ageing population, women are known to have higher rates of Alzheimer’s disease, relative to men. Although concussion is a potential risk factor in developing dementia, studies have not yet examined the interaction between SRC and neurodegenerative diseases in women.

long-term implications of single head impacts and repetitive concussions.

Therefore, female brains are thought to be hungrier than males, with greater blood flow resulting in faster metabolisms.

Sports-related concussion is a health concern, and women are at higher risk of sustaining a sports-related concussion compared to males. Although there have been studies that investigated outcomes after concussion, females remain an understudied population, despite representing a large proportion of the organised sports community. Making informed, evidence-based decisions about risk and benefit needs to rely on objective data in the form of prospective studies, in order to determine how concussions affect women across the lifespan.

Author Bio Shreya McLeod, is a Titled Sports & Exercise/ Musculoskeletal Physiotherapist, has more than 15 years’ experience treating national and international athletes. Shreya is currently undertaking a PhD at The University of

Prospective clinicopathological studies in women are needed to assess the interaction between repetitive exposure to head impacts and the potential changes in brain and behaviour across the lifespan. These studies need to apply a multifactorial approach by considering cognition, genetic risk factors, mental health, and menstrual cycle function pre- and post-injury, to better inform the

Newcastle, New South Wales, in the identification of concussion in Women’s National Rugby League. She has a research interest in injury risk reduction, particularly in female contact and collision sports. She is also a Lecturer in the undergraduate Physiotherapy program at the Australian Catholic University in North Sydney, New South Wales.

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FEATURE: PERSISTENT CONCUSSION SYMPTOMS

Persistent Concussion Symptoms Review of Current Evidence K. L. Williams, Specialist Neurological FACP 2008 and E. Warner, Titled Neurological APA

CONCUSSION IS A FUNCTIONAL DISRUPTION OF BRAIN TISSUE WITH SIGNS AND SYMPTOMS MORE READILY RECOGNISED AND ACCEPTED AS SEQUALAE OF THE MECHANISM OF A MILD TRAUMATIC BRAIN INJURY (MTBI). FORMAL DEFINITIONS FOR THE DIAGNOSIS OF CONCUSSION HAVE BEEN DEVELOPED AND PUBLISHED WITH STRICT CRITERIA. UNDERSTANDING SYMPTOMS BEGIN WITH UNDERSTANDING THAT TBI OCCURS AS A RESULT OF BRAIN DEFORMATION.

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he mechanism and directional forces of injury may play a critical part in reported symptoms and assessments completed. Other body structures can be affected by a concussive event (e.g., cervical, vestibular) and produce symptoms not related to brain tissue disruption, and should be considered in a multi-faceted assessment of a possible concussive event. This also includes trauma (e.g., motor vehicle accidents) and in the elderly population (e.g., following a fall). Consequently, guidelines outline that a diverse range of health professionals are involved in the recognition, and

FEATURE: PERSISTENT CONCUSSION SYMPTOMS

individualised assessment and management of a concussed individual. Persistent Concussion Symptoms As research expands and concussion symptoms are captured, longer lasting symptoms are being noted. These symptoms are being termed Persistent Concussion Symptoms (PCS), (previously post concussive symptoms). Persistent symptoms are those symptoms continuing beyond the expected timeframe of recovery (10-14 days in adults and four weeks in children) which present across somatic, cognitive and emotional domains (Bio-Psycho-Social) and fall within the following diagnostic formulae:

a) A physical hit or concussive force impact with generally immediate sequelae; b) core resulting symptoms including headaches, balance problems, dizziness, fatigue, sleep disturbance, noise/light sensitivity, visual changes and dysregulated mood; c) symptom course persisting beyond the expected recovery period; d) with refractory symptoms not better explained by another aetiology or maintained by secondary factors. Risk factors for the presentation of PCS include the severity of acute and subacute symptoms following the concussive event, particularly cognitive, vestibular, neck pain and post-traumatic headaches. Persistent

Photo: Alexander Medvedev/ iStock

Whilst the majority of attention for concussion research is in the area of elite athlete sports-related concussion and military research from blast injuries, it is important to acknowledge that these injuries also occur in amateur sports (e.g., “weekend warrior”).

concussion symptoms are also more common in individuals with a history of depression or anxiety, previous learning difficulties, personal or family history of migraine, and of the female gender. To further assist in the identification, assessment, and treatment of concussion symptoms (and PCS), research has highlighted concussion can be classified into subtypes (Cognitive, Oculomotor, Vestibular, Headache/Migraine and Anxiety/ Mood). Several associated symptoms (not directly related to brain pathology and symptoms) have also been identified, including sleep dysfunction and cervical conditions. VOLUME 39 • ISSUE 2 2022

FEATURE: PERSISTENT CONCUSSION SYMPTOMS

Persistent Concussion Symptoms

Review of Current Evidence

Assessment and management of persistent concussion symptoms Clinical Practice Guidelines for Physiotherapists published in 2020 recommend the following upon presentation of a person with symptoms post-concussion or suspected concussion. 1) Health professionals must screen all persons who have experienced a potential concussive event and document the presence or absence of symptoms, impairments and functional limitations. 2) Persistent symptoms of greater than three months require a multidisciplinary team approach using an individualised assessment and management program with reference to prior medical pathologies and symptoms. How to establish the correct team will rely on symptom and functional evaluation and interpretation. Symptom evaluation Patient reported symptoms guide the objective evaluation and align the classification profile. The tools used for symptom evaluation will have an impact as to the final classification profile established. Symptom evaluation tools currently lack suitable consistency and comprehensiveness, nevertheless, two tools are most utilised clinically. 1) The Sport Concussion Assessment Tool (SCAT)5 for 13 years and older, and SCAT5 for 12 years and under, provides a comprehensive tool for use in examination of an individual with concussion regardless of time since injury. This 22-item tool captures symptoms and intensity on a 7-point scale (0 = no symptoms, 6+ = severe symptoms). Ideally this tool should 10

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be utilised within 24 hours (office or off-field assessment) or as soon as the individual presents or is suspected of having suffered a concussion. 2) The Rivermead Post-Concussion Symptom Questionnaire (RCS) is a 16-item scale that captures key symptoms and intensity on a 5-point scale (0 = no symptoms, 4 = severe symptoms) experienced in the past 24 hours. Evidence suggests that the SCAT5 (Adult) and the RCS scores can be converted between the two scores optimising communication between health professions and monitoring of recovery. 3) The Post-Concussion Symptom Scale (PCSS) is a 22-item scale using a 7-point scale (0 = no symptoms, 6 = severe symptoms) is less commonly

Photo: Tonpor Kasa/ iStock

These subtypes are not mutually exclusive and concussed individuals may fall into several subtypes.

utilised yet is a simple tool to use, and captures similar symptoms to the SCAT5. With any of the above tools, caution in the interpretation of dynamic recovery of symptoms is required as the responsiveness of the PCSS to recovery is yet to be established and key subtype symptoms identified above are not well represented within the scales. Greater evaluation of pre-injury medical history including previous concussions or medical conditions that could present with symptoms similar to concussion-like symptoms is required to improve the differential diagnosis. Concurrent knowledge of other diagnoses and medication that may heighten symptoms or delay recovery is also crucial. For those persons who seek support weeks to months after a

FEATURE: PERSISTENT CONCUSSION SYMPTOMS

concussive event, a detailed evaluation of symptoms and irritability in the 3-4 weeks immediately after the event should be undertaken. As outlined, irritability and presence of symptoms in the first 3-4 weeks are potential predictors of prolonged recovery Physiological Testing Given the brain metabolic dysfunction that occurs in an individual post a concussive event and the prolonged symptoms of PCS, identification of a person with ongoing physiological symptoms should occur. The two key assessment tools for assessing physiological symptoms include the graded Buffalo Treadmill Test (BTT) or the Buffalo Concussion Cycle Test (BCCT). These tools provide a graded exposure to aerobic exercise.

Recent evidence highlights those nonconcussed persons with concussion like symptoms do not have the same increase in symptoms triggered by a physiological test.

Traditionally, these testing tools have been used more often in the acute stage post-concussion, however, for a person attending with prolonged symptoms, the physiological assessment may be warranted. The goal of the test is to provoke symptoms such as headache, fatigue, imbalance, dizziness or pain. The examiner monitors the heart rate (HR), perceived exertion, and symptoms during and concluding the test and monitors when the symptoms increase by 3 points from baseline. The HR at which symptoms reach an increase by 3 points is captured as the maximum HR. So, this assessment is valid for the identification of a person with physiological concussive symptoms, however, the exact physiological cause for these symptoms remains elusive, with recent evidence pointing to no difference in those with diagnosed PCS and normal for cardiovascular responses on the BTT. Recent evidence for the treatment of physiological

symptoms involves sub-symptom threshold cardiovascular exercise with early positive outcomes. This treatment involves the provision of exercise aimed at up to 80% of the HR that required physiological testing to be stopped for a minimum of 20 minutes (continuous or burst) daily, hence at sub-symptom thresholds. Vestibular and Oculomotor Central vestibular system integrators and oculomotor initiation and integration are primarily affected in PCS with up to 20% of persons with PCS reporting vertigo and 14% oculomotor symptoms. Peripheral vestibular and infra-nuclear ocular motility dysfunction are infrequently reported and if present, should be evaluated and managed as concomitant symptoms by a suitably trained vestibular health professional. For example, the incidence of Benign Positional Paroxysmal Vertigo (BPPV) is 28% in persons post-concussion. Identification of the affected canal by using infra-red video oculography during positional tests is usually assessed by the vestibular health professional. Other vestibular pathologies reported post-concussion include Menières, labyrinthine concussion, vestibular migraine, third window syndrome and psychogenic vertigo. Due to the complexities of the afferent and efferent vestibular system and central pathways, concussion guidelines recommend the evaluation by a specialist vestibular and neurological health professional. To capture vestibular/ocular dysfunction, the Vestibular Oculo-Motor Screening (VOMS) is the most used tool. This test uses a series of ocular motility (smooth pursuit, saccades and convergence) and vestibular (Vestibular Ocular reflex (VOR), VOR cancellation) tests to capture the abnormal findings/observations (from normal) and irritability of the test VOLUME 39 • ISSUE 2 2022

FEATURE: PERSISTENT CONCUSSION SYMPTOMS

Persistent Concussion Symptoms

Review of Current Evidence.

on symptoms of headache, dizziness, nausea and fatigue from a baseline. Treatment of vestibular symptoms has a good level of efficacy for the improvement of dizziness symptoms, balance and return to play/work, however, the benefits of oculomotor therapy as yet are inconclusive. Vestibular rehabilitation encompasses a mixed system approach utilising head movements with variable eye movements and balance strategies, requiring complex neuroadaptive integration of the visual, vestibular and proprioceptive systems to optimise motor control. It is likely that the combined systems approach to the rehabilitation of dizziness, visual and balance systems is the reason vestibular rehabilitation has thus far shown greater efficacy than oculomotor strategies alone. Identification of specific vestibular therapy strategies requires a targeted individualised treatment program. Experienced neuro-vestibular physiotherapists have the key skills to take the concussed and PCS individual from the differential assessment to treatments. Post-traumatic Headache/Migraine Headache or migraine is the most commonly reported symptom with concussion and PCS (26%). A prior personal or familial history of headaches/migraines is a primary risk factor for posttraumatic migraines. The usual associated pre- and pro-dromes can present as reported for primary migraines, including sensitivity to light/ sound/smell, nausea, vomiting and motion sensitivity. However, brain MRI studies have identified differences in brain morphology and brain responses between post-traumatic headaches and non-traumatic migraines, yet clinically they present similarly. Headaches require a focused headache history assessment, utilising the ICHD-II classification criteria. Treatment should 12

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be multi-factorial including nonpharmacological, with identification of triggers related to lifestyle, diet, sleep, stress, mechanical influences (neck, postures) and neuro-sensory integration overload (vision, vestibular, balance). Pharmacological scripting should be undertaken by a skilled neurologist or physician with advanced skill in management of headache syndromes, as there are a number of added ‘risks’ associated with the use of standard headache/migraine medication in a person with post-traumatic headaches. Anxiety/Mood Anxiety-related symptoms such as nervousness, hypervigilance, depression, anger and irritability are common to the client with PCS. It is estimated that 12-44% of concussed individuals will experience some degree of depression. The use of common Psychology tools or scales, such as the Becks Depression Inventory and Hamilton Depression Rating Scale may assist in identification. However, as symptoms of depression can mimic PCS, referral to a psychologist for further evaluation and management is essential, as in most cases depression is multifactorial. Cognitive/Fatigue Cognitive dysfunction such as reduced attention, reaction time, processing, memory and organisation are commonly reported in PCS presentations. These require the specialised assessment and management of a Neuropsychologist and are outside the scope of this article for detailed discussion. There are several assessment platforms in use to evaluate and treat cognitive dysfunction including ImPACT & CogStat, however, quality evidence for the use of these tools in identification and treatment of concussed individuals is still developing. Patient reported symptom profiles

can be used to capture or review symptoms of anxiety, mood, or cognitive difficulties to prompt those working with concussed individuals to refer. Early intervention programs are designed to promote uneventful recovery and resumption of normal activities. Evidence points to individuals who are concussed and show signs of resilience and flexibility in adapting to symptoms, have good family and social supports and are provided with education in their recovery after a concussion early on, and are less likely to develop PCS. Thus, early supported education and interventions with suitably skilled health professionals has significant positive impact in recovery timelines. Fatigue is also another complex symptom that requires specialised evaluation, as it is often multidimensional. All the above symptoms are associated with

Photo: Catherine Ivill/ iStock

FEATURE: PERSISTENT CONCUSSION SYMPTOMS

reports of fatigue. To this end, comprehensive subtype symptom analysis should enhance the health professionals’ capacity in optimal symptom treatments to reduce fatigue. Fatigue may also be influenced by sleep disturbances warranting consideration of how the concussion associated symptoms may interplay. In general, it is noted that fatigue declines with comprehensive multidisciplinary symptom management in those with PCS. Balance and Postural Control Impaired balance and postural control are commonly reported symptoms following a concussive event and in PCS presentations. Balance and postural control are a ‘final’ functional output of the integration and utilisation of multiple body systems that may be impaired after a concussive event. These systems include vision, vestibular,

proprioceptive input and motor output. The successful output of motor control for balance and postural control relies on optimal sensory inputs and central (brain) integration capacity. Optimal assessment of balance dysfunction after a concussive event should aim to capture the complexity of body system and neural integration required for optimal dynamic balance. Few of the current clinical balance assessments achieve this or have strong validity or reliability, consequently a combination of assessments may be required with greater emphasis on dynamic balance than quiet balance. Instrumented balance assessment tools have shown to have better validity and reliability than clinical balance assessments, however access is often limited to be of practical use. Current practice utilises balance tasks that aim to integrate visual, vestibular,

somatosensory inputs with motor control, and with variations to the task in an attempt to re-weight one body system over another. Balance Error Scoring System (BESS), Clinical Test of Sensory Interaction in Balance (CTSIB), Romberg and Tandem Walk (+ cognitive overload) are all common assessment tools. Each has a standardised protocol for testing and recording outcomes and are readily available free of charge. Treatment that targets an integrative approach to balance has shown to have positive benefits in the restoration of balance in concussed individuals. Many of the balance integration techniques are combined with vestibular rehabilitation strategies given the strong influence the vestibular and oculomotor systems have on balance. Again, skilled health professionals are required to ensure the optimal individualised mix of strategies are employed. VOLUME 39 • ISSUE 2 2022

FEATURE: PERSISTENT CONCUSSION SYMPTOMS

Persistent Concussion Symptoms

Review of Current Evidence.

Concussion-Associated Conditions Cervical Dysfunction Neck dysfunction is often a concurrent symptom reported after a concussive event. An individual with neck dysfunction after concussion, reports many symptoms similar to those reported post whiplash. Cervical integrity assessments are required in the acute concussive individual and persons with PCS should have their neck examined for movement, neuromuscular and sensorimotor control, given the integral relationship of the proprioceptive and mechanical tools of the upper cervical spine to the brainstem for postural and neurosensory control. People with neck dysfunction often describe symptoms similar to those reported in PCS individuals including dizziness, imbalance and altered vision. Key assessment points should include range of motion, localised palpation, evaluation of pain triggers, cervical strength (sustained flexion, extension strength), and sensorimotor control (joint position sense, smooth pursuit neck torsion test). Treatment of cervical spine has good evidence in the reduction of associated neck dysfunction and other symptoms such as dizziness and imbalance associated with PCS. When combined with vestibular rehabilitation, it also reduces time to return to work for a concussed individual. Sleep Disturbance Sleep disorders have been studied in post concussive presentations and they can exacerbate other concussive symptoms and contribute to prolonged recovery times. Insomnia, sleepiness and sleep apnoea are some of the sleep disturbances experienced by clients (more in females) following concussion injury and those with PCS. The mechanism of injury, whether it be sports-related or non-sportsrelated, may contribute to the type of sleep disturbance experienced. 14

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The mechanism of injury, whether it be sports-related or nonsports-related, may contribute to the type of sleep disturbance experienced.

Comprehensive evaluation of sleep in PCS helps to determine sleep-wake patterns pre- and post-concussion and will enable tailored advice and strategies to be provided to the client. There are a variety of sleep questionnaires that can be used, including the Pittsburgh Sleep Quality Index to help identify areas of concern. Ideally any PCS individual with sleep disturbances should undergo a comprehensive sleep assessment by a sleep specialist. Sleep hygiene advice may include details around habits and routines of sleep times, considerations around diet, exercise and lifestyle, sleep space and where appropriate, advice around supplements (e.g., Magnesium, B vitamins, Melatonin), acupuncture, mindfulness, and access to daytime light. Cognitive Behavioural Therapy (CBT) may also be provided by an appropriate health professional to manage sleep disturbance.

Supplementary Therapies Diet The benefits of adequate nutrition when managing PCS are numerous. It can enhance the healing processes and potential for recovery and consequentially, improve concentration, memory, sleep and hormonal balance (e.g., stabilise blood sugars). In turn, this can improve the client’s sense of independence and control in their recovery. Improved nutrition can also improve mood and increase perceived energy levels. Some key dietary or supplemental nutrients include Omega-3 fatty acids, Omega-6, C, D, E and B group vitamins, curcumin, melatonin and good bacteria from fermented foods. In addition, good hydration, and avoidance of stimulants, such as caffeine and refined sugars is also advised. Mindfulness Mindfulness-based stress reduction techniques have been shown to improve memory, attention, mood and tolerance for stressful situations post-concussion. This meditation type technique can have positive effects on both physiological and psychological states and can enhance resilience and treatment responses overall. Education and Symptom Management Depending on the presentation of symptoms (i.e., intensity, frequency, duration, irritability), education to the client with PCS is important. The client will need to acknowledge their level of baseline symptoms and monitor them throughout their recovery, and particularly when returning to activities (e.g., daily tasks, cognitive load, physical activity), so they can learn strategies for pacing and relative rest (e.g., switching between cognitive load and physical activity). By employing strategies for management, the client will be able to increase their tolerance

FEATURE: PERSISTENT CONCUSSION SYMPTOMS

to activities without increasing their symptoms to a significant level. Part of this education is to reiterate that complete rest may even delay their recovery, but excessive exertion can exacerbate symptoms of PCS. Many clients with PCS will have a goal of returning to their usual activity, whether it be cognitive (study, school, work) or physical (sports or general physical activity). So, education about symptom

management and pacing will guide the advice for attainment of these goals. If physiological symptoms are limiting return to activity, aerobic exercise at subsymptom thresholds (as determined by testing) is recommended or if cognitive symptoms are limiting activity return, then individualised strategies are recommended. Advice and strategies should be guided by the appropriately trained health professionals depending on the symptoms being managed.

Conclusion / Summary The presentation, identification and management of PCS is a multi-faceted process and relies on the efforts of a specialised team of health professionals. It is important to acknowledge this and depending on one’s area of expertise, recognise the signs and symptoms that warrant referral to the appropriate professional, in order to holistically manage the client with PCS with best evidence-based methods.

Author Bio Katrina Williams is a specialist Neurological

Emma Warner is an Australian

Physiotherapist FACP 2008 (as awarded by

Physiotherapy Association (APA) Titled

the Australian College of Physiotherapy).

Neurological Physiotherapist and

She has worked extensively in the fields of

Physiotherapy Lecturer at Griffith

neurological and vestibular rehabilitation for

University. She undertook her Bachelor of

over 20 years, with a focus on central vestibular pathologies

Physiotherapy, and Masters of Physiotherapy (Neurology)

including Multiple Sclerosis, Cerebellar dysfunction,

at The University of Queensland. She has worked in

Myasthenia Gravis, Motor Neuron Disease and Concussion

hospital and community sectors and Physiotherapy

to name a few. She works full-time at the University of

education in Southeast Queensland, as well as many

Queensland as a Senior Lecturer, Clinical Academic and runs

years working in London, United Kingdom.

a private practice Upright Physiotherapy in Brisbane and professional Education Group called Neurological Ageing

Emma has a special interest in Vestibular and Balance

and Vestibular Education – ‘NAVE’. She holds multiple

Rehabilitation and as a Neurological Physiotherapist, has

degrees in the field of Physiotherapy including a Graduate

many years of experience in this field. She worked as the

Certificate in Higher Education and has recently submitted

Specialist Physiotherapist in the Dizziness and Balance

her PhD in the area of somatosensory symptoms

Clinic in London, UK, for over five years and has developed

experienced by people with Multiple Sclerosis and impact

special skills in the rehabilitation of dizziness and balance

on function. She is actively engaged in ongoing research

dysfunction, including the rehabilitation of Concussion.

exploring the signs and symptoms of people complaining

She has also worked closely with Neurologists in the

of dizziness across the spectrum of musculoskeletal to

field of Concussion and was involved with the set up a

neurological pathologies with her latest research exploring

Concussion Service at the Institute of Sport, Exercise

the association of impairments of vestibular peripheral and

and Health (UCL) in London. She has a keen interest in

central integrative function in Multiple Sclerosis, Migraine

researching this area and has conducted courses on

associated vertigo, Concussion and the Elderly vertiginous

the management of concussion in Physiotherapy.

patients. Her research runs from the only University based vestibular and balance testing research facility in a Queensland University, which includes a Rotary Chair. This will provide the opportunity for more advanced testing and interpretive research for the dizzy person.

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2021 SMA E-CONFERENCE WRAP UP

2021 SMA e-Conference

Wrap Up OCTOBER SAW SMA HOST THEIR FIRST EVER VIRTUAL E-CONFERENCE AFTER THE COVID-19 PANDEMIC CONTINUED TO CAUSE INTERRUPTIONS TO STATE AND INTERNATIONAL TRAVEL AS WELL AS VENUE DENSITY LIMITS. THE FLIP TO THE ONLINE FORMAT GAINED A POSITIVE REACTION, WITH OVER 470 DELEGATES FROM 10 COUNTRIES INCLUDING AUSTRALIA, IRELAND, JAPAN, MALAYSIA, NETHERLANDS, NEW ZEALAND, PORTUGAL, SINGAPORE, UK AND USA TUNING IN ACROSS BOTH THE SUMMIT AND THE SHOWCASE.

he 2021 SMA e-Conference saw the best in Sports Medicine battle it out for a share in over $23,000 across the areas of Sports Injury Prevention, Clinical Sports Medicine, Physical Activity and Health Promotion, and Sport & Exercise Science, proudly sponsored by ASICS. The coveted 2021 ASICS Medal was awarded to Professor David Lubans from the University of Newcastle for the best overall paper – ‘Time-efficient physical activity intervention for older adolescents: The Burn 2 Learn cluster randomized trial’. Along with the ASICS Medal, Professor Lubans won the Senior Career Research Award (Physical Activity and Health Promotion). The two Senior Researcher awards of $2000 went to Dr. Kade Paterson for work in Clinical Sports Medicine & Professor David Lubans for their paper on Physical Activity and Health Promotion. The Early Career Researcher

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Awards for researchers up to five years post-doctoral were taken out by Rachael Cowan who wrote on Clinical Sports Medicine, Margot Rogers with a piece on Sport and Exercise Science, Tess Rolley who was looking into Sports Injury Prevention & Lisa Olive with the best paper on Physical Activity and Health Promotion.

This e-Conference would not have been possible without the support of our Major Partner ASICS, The Summit naming sponsor Bared Footwear and The Showcase naming sponsor Hydralyte Sports. We also provide the opportunity for a first ever online Trade and Exhibition Portal featuring ten online trade stands.

The Wendy Ey Award is awarded for Women in Sport. This Best Paper Award went to Gabriela Mena Ribadeneira.

The 2021 SMA e-Conference would not have been possible without the devotion of committee – Co-Chairs, Dr Luke Kelly and Dr Ebonie Rio and committee members, Dr Andrea Mosler, Myles Murphy, Dr Adam Castricum, Dr Sally Clark, Associate Professor Mitch Duncan, Dr Reidar Lystad, Professor Dara Twomey and SMA Board Deputy Chair Kay Copeland.

The ASICS Best Poster awards were tightly contested but the final recognition went to Maree Cassimatis for her work with Clinical Sports Medicine, Antony Stadnyk for his piece on Sports and Exercise Science, Tyler Collings who specialized in Sports Injury Prevention, and Jane ShakespearDruery for her piece around Physical Activity and Health Promotion.

As we look back on the success of the 2021 SMA e-Conference, we look forward to what the 2022 SMA Conference may hold!

2021 SMA E-CONFERENCE WRAP UP

David Lubans 2021 ASICS Medal - Best Paper Overall Professor David Lubans

Tess Rolley ASICS Best Paper (Sports Injury Prevention)

Margot Rogers ASICS Best Paper (Sport and Exercise Science)

Gabriela Mena Ribadeneira Wendy Ay Award Best Paper

Tyler Collings ASICS Best Poster (Sports Injury Prevention)

Maree Cassimatis ASICS Best Poster (Clinical Sports Medicine)

Rachael Cowan ASICS Best Paper (Clinical Sports Medicine)

Antony Stadnyk ASICS Best Poster (Sport and Exercise Science)

Jane Shakespear-Druery ASICS Best Poster (Physical Activity and Health Promotion) VOLUME 39 • ISSUE 2 2022

FEATURE: THE CONCUSSION CRISIS IN SPORT

The Concussion Crisis

A Sociological Perspective

Dominic Malcolm – Loughborough University, United Kingdom

THE BEGINNING OF 2022 IS A PERTINENT POINT AT WHICH TO REFLECT ON THE ISSUE OF CONCUSSION IN SPORT. FOR 40 YEARS NOW, ORGANISATIONS SUCH AS THE BRITISH MEDICAL ASSOCIATION HAVE CAMPAIGNED FOR THE ABOLITION OF BOXING DUE, PRIMARILY, TO CONCERNS ABOUT BRAIN INJURY. 18

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t is also 21 years since the first International Conference and Agreement Statement on concussion in sport, an event which marked the start of the sports medicine community’s attempt to formalise and more systematically advance the science of concussion. It is 20 years since the death of Mike Webster, and the post-mortem which led to the NFL’s landmark $1 billion legal settlement with ex-players elevating concussion from a routine sports injury to a widespread social crisis. It is also 21 years since concussion was first described as an ‘epidemic’ in scientific literature. In the last two years,

COVID-19 has changed the way all of us – public and health professionals – think about epidemics and their global ‘big brother’, pandemics. The debate over Novak Djokovic’s eligibility to play in the 2022 Australian Open is a case in point. Although it is important to draw a distinction between an epi/ pandemic as technically defined – notably concussion is neither a disease nor infectious – increasingly, non-communicable diseases are being classified in these terms. Importantly, regardless of aetiology, when conditions reach epidemic proportions, they invoke a particular social reaction. ‘Epidemic psychology’, Peter Strong first noted, consists

FEATURE: THE CONCUSSION CRISIS IN SPORT

in Sport

Photo: PeopleImages/ iStock

some sports is under threat, while for others, proposed rule changes (e.g., removing tackling in rugby or heading in soccer) lead to questions about whether the very essence of these activities will be destroyed. The concussion ‘pandemic’ seems some way off resolution, and it is changing the way we think about sports injury.

What all this goes to show is that understanding how science and society interact is vital.

of divided populations set against each other, widespread fear of what might happen in the future, a frantic search for explanations, and kneejerk calls for immediate action. There is then good reason to consider concussion in this way. What I have previously termed The Concussion Crisis in Sport continues to affect an increasing number of participants in an increasing number of sports across an increasing number of nation-states. Indeed, it is not an exaggeration to say that cultural concerns about sport-related concussion pose either existential or axiological challenges to sport – the very existence of

As a sociologist who writes about concussion and sport, my role is to identify how our perceptions of illness and injury change over time, and how these perceptions are connected to a broader social context. Consequently, in this article, I want to outline the major contours of the social debate about concussion, identify the social processes responsible for thrusting concussion into the public eye, and consider what this means for sports medicine clinicians. I conclude by returning to ideas about COVID-19 and pandemics, to provide some thoughts on the future of the crisis of concussion in sport. The Debate Debates about concussion in sport have usefully been described as a clash of values between those who see injuries (especially to children) as fundamentally problematic, and those who see injuries as a necessary evil, or an unfortunate side-effect that can be tolerated because the harms are offset by the benefits of sports participation. Concussion campaign groups argue that sports organisations have not moved fast enough, that resistance to change is inspired by self-interest, and that sports medicine does not show sufficient independence from the interests of these corporate paymasters. Advocates of more limited change (for I think we have passed the point where many people are willing to take a ‘no-change’ position) point to the lack of evidence of significant harm, uncertainty about what mechanisms cause what VOLUME 39 • ISSUE 2 2022

FEATURE: THE CONCUSSION CRISIS IN SPORT

The Concussion Crisis in Sport

A Sociological Perspective

neurological effects, and thus how much needs to change. The debates about concussion (just like COVID-19) are hampered by the relatively limited stock of reliable and valid knowledge, and this vacuum draws in much highly emotive posturing (just like COVID-19).

First, I would argue that the history of modern sport is characterised by a series of rule changes designed to reduce harm to health (admittedly, they don’t always work as intended) and that these align with a more general trend in the reduction and control of violence within society over time. Second, I would argue that a central reason why sports remain popular is because they provide an area of social life where relatively high levels of violence are relatively highly tolerated. Third, certain sports, and certain ways of playing sport, are more dangerous to health than others. Elite sports, and elite combat/contact sports in particular, stand out as some of the most dangerous occupations existing today. Equally – and this is a more personal position based on a reading of the scientific evidence and not something necessarily shared by sociologists – the number of former American athletes confirmed with CTE, and the FIELD study in the UK which showed that former professional soccer players were three times more likely to have a neurodegenerative disease cited on their death certificate, provide persuasive evidence that sports (both 20

VOLUME 39 • ISSUE 2 2022

Photo: Alexander Medvedev/ iStock

Sociologists – like members of any other academic discipline – will take a position on these ethical debates. But the distinct thing sociologists can offer is a perspective on where these debates sit within the longer-term development of sport. This leads us to identify three points. What I am about to say is a position that is fairly widely shared among sociologists of sport, but admittedly not universally held.

certain types of sport and sports played under particular conditions) pose distinct risks of brain injury. In many ways then, the concussion crisis is the continuation of a long-term trend. Sports will continue to adapt to changes in social attitudes about acceptable levels of injury, will always entail a relatively high level of risk, and the health harms evident in elite sport will always be at the upper end of what is socially tolerable. Yet there is clearly something different in the concerns about concussion expressed in the here and now. Why is that?

The social roots of the concussion crisis Here I highlight four of the more important factors. Firstly, sports have become increasingly important to the way people identify with the nation. In a global world, the hosting of mega events, the performance of national teams, and the staging of ‘national’ sports events have increasing symbolic significance. Note how the debate about Djokovic became a distinctly nationalist issue. Tellingly in relation to concussion, any individual nation’s debate has

FEATURE: THE CONCUSSION CRISIS IN SPORT

tended to focus on its ‘national sport’: American football, ice hockey in Canada, soccer in England, rugby union in New Zealand and of course Australian rules football. What this tells us is that the concerns are not simply driven by the frequency and severity of concussion, but what playing those sports means to the people of those countries. Secondly, the nature of sports celebrity has also changed. From around the turn of the millennium (and so coincident with a step change in social concerns about concussion) the public’s relationship with sports celebrities became more intense, more personal, more intrusive. Where once the public primarily focused on an individual’s sporting performance, interest in their lives is now more holistic. The changing nature of the mainstream and social media have enabled athletes to remain in the public eye after sporting performance has waned. Shane Warne’s new autobiographical documentary is a good example of this. Linked to celebrity is the growth in sporting nostalgia. The growth of nostalgia is a wider social development, in part linked to an ageing population. But in sport, once again, the turn of the millennium was significant. While a much longer established tradition in North America (the NFL’s Hall of Fame opened in the 1960s and the NHL in 1943), the Australian Football Hall of Fame was established in 1996. Similarly, England’s National Football Museum and Australia’s National Sports Museum were founded in 2001 and 2008 respectively. This reflects a growing demand for sporting nostalgia. Not only are people more deeply interested in the lives of sports stars, we continue to do so as they enter old age and thus,

To understand this we need to ask, what are the broader social changes affecting sport that have led concussion to take on the significance it has today?

the time when neurodegenerative conditions are likely to develop. Indicatively, in England much of the discussion of concussion fascination surrounds the neurological health of the 1966 World Cup winning team. Finally, both within and outside of sport, attitudes towards mental health and dementia are changing. Dementia, once seen as a relatively unremarkable aspect of the ageing process, has become one of the global health priorities of our age. Social concerns centre on the potential burden in terms of economic cost and emotional care. Generally speaking, while medical progress helps people live longer and longer, existing treatments of brain related diseases and conditions are relatively limited. Combined, these factors lead society to treat dementia differently to other health conditions. For instance, there is a growing body of evidence linking sport and motor neuron disease, but those athletes affected are portrayed very differently in the press to exathletes with dementia. This difference is why Bennet Omalu’s autopsy of Mike Webster was seminal in reshaping concerns about concussion, why it featured in a Hollywood film.

Impact on Sports Medicine Professionals With these social processes thrusting the issue of concussion into the public eye, the work of sports medicine clinicians has inevitably been affected. On one level – as alluded to above – this has led to greater scrutiny of the profession. Much has focussed on the Concussion in Sport Group consensus statements – the resistance to linking CTE with sport participation, the lack of procedural transparency, the potential conflicts of interests, and the pool of expertise informing these statements. While there is clearly room for these processes to become more robust, a lot of these critiques miss the importance of these early statements in developing the science of concussion in sport, and the currently limited emphasis public health researchers place on the role of traumatic brain injury as a risk factor for dementia (see e.g., the Lancet Neurology’s identification of risk factors for dementia). Equally, the practice of individual sports clinicians on the field of play has been subject to greater scrutiny and criticism. There is a clear contradiction between the scientific view of concussion as being complex and difficult to diagnose, and the apparent simplicity of the condition to those watching television VOLUME 39 • ISSUE 2 2022

FEATURE: THE CONCUSSION CRISIS IN SPORT

The Concussion Crisis in Sport

A Sociological Perspective

and posting on social media. While individuals will undoubtedly find this dissection painful, in the longer term and in a more general sense, public scrutiny will likely improve the accuracy and consistency of medical and scientific practice. A second impact is the potential to strengthen the independence of clinical decision making in sport. Much has been written about the distinct pressures sports healthcare providers face from athletes and coaches. In qualitative research, many of those questioned have talked about the potential for such pressures to compromise their medical advice and proscriptions. Nowhere was this more evident than in the treatment of concussion when those practicing sports medicine have felt unsupported by the scientific evidence, and often isolated in their attempts to advocate precaution over concussion injuries. Revised concussion protocols and wider public awareness will likely provide practitioners with better institutional and social support and anything which bolsters clinical autonomy for sports medicine 22

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While all epi/pandemics are characterised by a particular cycle of psychology, the response to COVID-19 has raised a number of questions which are equally pertinent to the social management of concussion.

practitioners should be welcomed. The wider hope is that there is a kind of trickle-down effect, and the profession experiences greater independence across all aspects of practice.

The future of the concussion crisis As noted above, COVID-19 has changed the way all of us think about public health and, in particular, how social factors interact with medical science. While all epi/pandemics are characterised by a particular cycle of psychology, the response to COVID-19 has raised a number of questions which are equally pertinent to the social management of concussion. First, what we see in both cases, is a delicate balance between public health restrictions and civil liberties. The more we restrict physical contact between individuals the safer the world would likely be, but can such restrictions on human freedoms be justified, and to what extent are we trading physical health benefits with mental health costs? Second, in relation to both COVID-19 and concussion, we are becoming increasingly aware of the limitations to the scientific management of certain ‘illnesses’. How accurate are our epidemiological evaluations, how much is incidence affected by public attitudes and awareness, and how efficacious are our technological solutions? Increasingly we are having to ask for

Photo: Adam Calaitzis/ iStock

FEATURE: THE CONCUSSION CRISIS IN SPORT

how long and against which variants will vaccines work, and similarly more accurate measures of physical impact, or reliable diagnostic biomarkers, will only change rather than resolve the issues around concussion in sport. Finally, through COVID-19 we have come to be increasingly aware of the complexities of the social management of pandemics. These measures, as for concussion, have revealed the difficulties of gaining compliance through education, the prominence of ‘fake news’ and disinformation spread via social media, and the increasing polarisation of views in modern societies.

Author Bio Dominic Malcolm is Reader in the Sociology of Sport in the School of Sport, Exercise and Health Sciences at Loughborough University, UK. He has published widely in the sociology of sport including Sport: Critical Concepts in Sociology (2003, co-edited with E. Dunning), the Sage Dictionary of Sports Studies (2008), Sport and Sociology (2012), and Sport and Society: A Student Introduction (2016, co-edited with Barrie Houlihan). His research uses sociology and qualitative methods to explore the intersections between sport, health and medicine.

Concussion is likely to remain the No. 1 public health issue in sport. In some respects, Australia was a world leader in recognising this and, by comparison, the UK government has just made its first official policy declaration regarding concussion and sport. In both countries, understanding the medical science and the social context is vital to our effective management of issues crucial to the longer-term role of sport in society.

The research iniitally focussed on how athletes self manage their injuries, and how healthcare providers work in the field of sport. He has published The Social Organization of Sports Medicine (2012, co-edited with Parissa Safai), has recently completed a book titled Sport, Medicine and Health: the medicalization of sport? and in 2020 published The Concussion Crisis in Sport. He is currently the editor-in-chief of the International Review for the Sociology of Sport, and a Research Fellow of the North American Assocation for the Sociology of Sport.

VOLUME 39 • ISSUE 2 2022

Photo: AlexLMX / iStock

FEATURE: CAT T – THE CONCUSSION AWARENESS TRAINING TOOL

A Decade of Providing Evidence-based Concussion Education

CATT – the Concussion Awareness Training Tool Kate Turcotte, Samantha Bruin, & Shelina Babul

NO LONGER SEEN AS “PART OF THE GAME”, CONCUSSION IS NOW WIDELY RECOGNISED AS A TRAUMATIC BRAIN INJURY BEYOND THE WORLD OF SPORTS. FOR THE LAST TEN YEARS, AN INNOVATIVE PLATFORM HAS BEEN SUCCESSFUL IN RESPONDING TO THIS TREND, WITH THE GOAL OF EDUCATING THE PUBLIC ON THE IMPORTANCE OF TIMELY AND APPROPRIATE ATTENTION AND MANAGEMENT OF CONCUSSIONS.

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he Concussion Awareness Training Tool, known as CATT and cattonline.com, is an online concussion education platform for diverse, targeted audiences. What began as one educational module for health care professionals has become a complex program serving a variety of audiences. CATT addresses the national and international need for reliable concussion information. It is available at no charge, incorporating

FEATURE: CAT T – THE CONCUSSION AWARENESS TRAINING TOOL

international guidelines and evidencebased resources. In addition, each evaluated educational module includes a downloadable package of tailored resources such as strategies for returning to school, sport, work, and general activity. International response to concussion Starting in 2001 in Vienna, followed by Prague 2004, Zurich 2008, Zurich 2012, and Berlin 2016, International Consensus Conferences on Concussion in Sport have been held to bring together top brain injury experts to form standardised guidelines for concussion diagnosis, response, and management. This initiative is recognised today as best practice, and has stimulated renewed research on the subject. It also expanded the issue of concussion from professional adult athletes playing sports such as football and hockey, to youth sports. A recent commentary has called for the Consensus approach to expand the focus beyond sports, and to consider patient and caregiver perspectives. The next International Consensus Conference on Concussion in Sport is scheduled for Amsterdam in October 2022, having been delayed due to the global COVID-19 pandemic, and is anticipated to result in significant updates. Bridging the gap In the late 1990s and early 2000s, concussions were a hidden epidemic that plagued sports players and society as a whole. Players were told to “suck it up” and that they just “got their bell rung” – when in fact, this attitude can lead to slow recovery and long-term consequences. In response to this misconception, CATT was conceived by Dr. Shelina Babul at the British Columbia (BC) Injury Research and Prevention Unit in Vancouver, Canada ten years ago. From her position at the BC

To date, the CATT e-learning modules have been completed over 75,000 times by people from over 50 countries, and mandated by over 70 organisations and schools. Children’s Hospital, Dr. Babul found herself fielding telephone calls from distressed parents who had sought medical care for their concussed children, and yet were confused about diagnoses, treatment and management options, and recovery expectations and timelines. A study undertaken in Toronto, Canada around this time also found gaps in knowledge and practice among physicians treating sports concussion. In consultation with pediatric emergency department physicians and nurses, Dr. Babul proposed to bridge the gap in knowledge between concussion research and clinical care. The goal of this new tool was to increase awareness of concussion as a serious injury and to equip healthcare professionals with knowledge to better support their patients. CATT for Medical Professionals launched in 2013, with support from provincial organisations Child Health BC and Doctors of BC. The videobased course included the etiology of concussion, signs and symptoms, assessment, and treatment and follow-up. Content covered concussion for the general population as well as paediatric-specific information. Expert Talks videos were contributed by Sports Medicine specialist Dr. Jack Taunton (University of British Columbia) and neurosurgeon Dr. Charles Tator (University of Toronto). Online versions of the SCAT3 and

Child-SCAT3 assessment tools were developed. A pre/post intervention evaluation demonstrated a statistically significant positive change in concussion practices among physicians (p = 0.001) and improved concussion knowledge among physicians seeing more than 10 concussion cases per year (p = 0.039). Around this time, the Canadian Paediatric Society updated their recommendation that anyone involved in child and youth sport should be educated about the signs and symptoms of concussion, and the appropriate management of a child with a concussion. With a focus on youth athletes, next steps saw the creation of CATT resources for parents and volunteer communitybased coaches, focusing on concussion recognition, response, and management (2014). Parents are central to the management of their child’s concussion recovery, responsible for seeking medical attention, dayto-day monitoring, and following treatment guidelines. Coaches need to be able to identify high-risk activities, compile pre-participation information, and to take appropriate action in a potential concussion situation. These modules highlight the leading causes of concussion in addition to participation in sports, signs and symptoms, the need for both physical and cognitive rest, and the risks of second-impact syndrome. Pre/post intervention evaluation VOLUME 39 • ISSUE 2 2022

FEATURE: CAT T – THE CONCUSSION AWARENESS TRAINING TOOL

A Decade of Providing Evidence-based Concussion Education

CATT – the Concussion Awareness Training Tool demonstrated significant positive change in concussion knowledge among parents/coaches (p = 0.002). Concurrently, in lieu of a “concussion course”, selected videos and resources were curated for youth, focusing on what a concussion is and how it occurs, symptoms, and the importance of acknowledging a potential concussion. Aside from development of these modules, Dr. Babul worked tirelessly to raise awareness of CATT, delivering presentations to schools, medical organisations, and presenting her work at conferences around the world. She spoke to the media to educate the public about the risks of undiagnosed brain injury; over the past decade, she has provided over 75 media interviews on concussion and brain injury. These efforts have proved successful; in 2016, CATT for Coaches was mandated by BC Hockey, the governing body for all youth hockey leagues in British Columbia, for all on-ice officials, with a QA/QI study finding strong support for the resource. More recently, the governing organisation for school sports in the province, BC School Sports, mandated CATT for Coaches for all school coaches, teacher sponsors, trainers, and team managers in 2020. In 2015, the province of British Columbia indicated that the government’s approach to addressing concussion in sport was through education rather than legislation, as opposed to Ontario passed legislation incorporating education. With the continued focus on youth athletes, concussion management extended to the broader picture of support for resuming life after concussion. For a student, concussion recovery entails balancing competing activities: schoolwork, sport and extracurricular activities, work for those with jobs, social life, and the increasing infiltration of technology into daily life. 26

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CATT for School Professionals (2016) was developed in consultation with experts from the regional rehabilitation centre: the G.F. Strong Rehab Centre School Program and the Adolescent Complex Concussion Clinic. The goal was to support students in participating in school without exacerbating concussion symptoms, or having a negative impact on academic success or social relationships. The approach is collaborative, with a designated school contact coordinating communication among members of the student’s support system, including the student and their parent/ guardian, classroom teachers, school administrators, school counsellor, and others. Resources include a return to school strategy, and a return to learn planning tool with suggested learning accommodations to address specific

symptoms and challenges. The pre/ post intervention evaluation of CATT for School Professionals demonstrated significant positive change in concussion knowledge among teachers and school administrators (p = 0.027). The promotion of this course was enhanced by two initiatives in the Lower Mainland of British Columbia, one a regional health authority project via Public Health contact with schools, and the other as a School District initiative regarding the development of concussion policy and continuing education. Having built the reputation as a wellmanaged, evidence-based online concussion resource, CATT was recognised by the Canadian Concussion Harmonisation Project, a federal initiative to coordinate and support the

Photo: Svetlana Glazkova / iStock

FEATURE: CAT T – THE CONCUSSION AWARENESS TRAINING TOOL

I always say: concussions can happen to anyone, anywhere, at any time. Everyone has their own unique life experience and situation. Shelina Babul

promotion and uptake of consistent evidence-based concussion information. Under this umbrella, CATT for Medical Professionals (2018) was redesigned, moving beyond raising concussion awareness among healthcare professionals to providing in-depth information on assessment, shortterm management, and addressing prolonged symptoms. The new resource blends videos and interactive course material, organised to include: definition and epidemiology; medical assessment including adjunctive tests; management and medical clearance including what to inform the patient; and persistent symptoms including making referral decisions. Additional resources include an online version of the SCAT 5/Child SCAT 5, and templates for medical assessment and medical clearance letters. A QA/QI study was undertaken to assess this updated resource, looking at sources of referral, self-reported learning and change in practice, use of the SCAT5 via CATT, patient referral to CATT, and recommendation of CATT to colleagues. The top three sources of referral to CATT MP were reported to be from a colleague, internet search, and email; 85% of respondents reported learning new information about concussion diagnosis, treatment, or management. Of respondents who see patients/clients with concussion, 73% reported changing the way they diagnose, treat, or manage concussion; 45% reported accessing the SCAT5 or Child SCAT5 from the CATT website; 48% distribute CATT materials or refer patients/clients to the CATT online resource; and 71% had recommended CATT to other medical professionals. Following this work, the remaining original CATT modules were updated: CATT for School Professionals (2019), CATT for Coaches (2019), and CATT Parents and Caregivers (2020). As part

of the Concussion Harmonisation Project, all CATT eLearning modules were translated and now available in both of Canada’s official languages, English and French. A further update to CATT for Medical Professionals (2020) incorporated the roles of physiotherapy and occupational therapy in concussion management. Beyond the world of sport Next steps in the expansion of CATT focused on non-sport related concussion in the adult population. Formative research was undertaken to understand needs and concerns. Interviews were conducted with healthcare and workplace professionals, and with people from various industries who were experiencing concussion or had returned to work following a concussion. This work highlighted: an ongoing lack of public awareness of concussion beyond sport; ongoing need for support from healthcare professionals, specifically in relation to mental health challenges during concussion recovery, and the stigma attached to invisible injury. Twenty adaptations or supplements to increase the accessibility of online health information by adults experiencing concussion symptoms were identified and used to inform the development of CATT for Workers and Workplaces (2019), with content and new materials reviewed by WorkSafeBC. This work also led to a collaboration with the motion picture, film, and live performance industry. Many workers, including stunt performers, are at high risk for injury. Collaboration with the Union of British Columbia Performers (UBCP/ACTRA) resulted in the development of tailored concussion resources for this unique population. Subsequently, Dr. Babul collaborated with SOAR – Supporting Survivors of Abuse and Brain Injury – a VOLUME 39 • ISSUE 2 2022

FEATURE: CAT T – THE CONCUSSION AWARENESS TRAINING TOOL

A Decade of Providing Evidence-based Concussion Education

CATT – the Concussion Awareness Training Tool multidisciplinary research collaboration between the University of British Columbia-Okanagan and the Kelowna Women’s Shelter. CATT for Women’s Support Workers (2020) is based upon previous research specific to concussion occurring within this oftenoverlooked high-risk population— survivors of intimate partner violence. Collaborators at SOAR have invested significant time and resource in evaluating this module, delivering workshops, and promoting it among frontline workers in women’s shelters. Returning to the needs of youth athletes, Dr. Babul was approached by U SPORTS, the Canadian national university sports-governing body, with a request to develop concussion education targeted to high performance athletes. CATT for Athletes (2021) was developed with a similar format to CATT for Medical Professionals, where participants work their way through the module, presented as videos, text, and interactive components. Content includes the importance of reporting, how concussion can affect daily life, and coping during recovery. Looking to the future Dr. Babul’s program of success is in large part due to her collaborations and the integrated knowledge translation approach – developing concussion education in consultation with stakeholders and end-users. She has collaborated with people representing each target audience to ensure content is relevant. So, what’s next? Currently, Dr. Babul is working on bringing concussion education to sports resources providers in Kenya and Tanzania, an extension of a preCOVID-19 pandemic pilot project that was conducted in Uganda. Dr. Babul is also expanding concussion education 28

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With CATT, we are trying to help people understand how a concussion can affect them personally. Shelina Babul

for athletes with the creation of a new CATT module for youth (to be launched following evaluation), in collaboration with the national NFLfunded research team – Surveillance in High Schools to Reduce the Risk of Concussions and their Consequences: SHRed Concussions. CATT for Youth will cover similar content as CATT for Athletes, but for a younger audience within the high school context. In a completely different direction, Dr. Babul is also collaborating on a project to pilot the use of virtual reality in helping first responders understand the signs and symptoms of brain injury. Links https://cattonline.com/ https://twitter.com/cattonline https://www.facebook.com/cattonline

Author Bio Dr. Shelina Babul is the Associate Director and Sports Injury Specialist with the BC Injury Research and Prevention Unit at BC Children’s Hospital, Vancouver, Canada. She is a Clinical Professor in the Department of Pediatrics at the University of British Columbia (UBC), and an Investigator with both the BC Children’s Hospital Research Institute and the Djavad Mowafaghian Centre for Brain Health at UBC. Dr. Babul specializses in concussion and traumatic brain injury with a focus on identifying and addressing critical gaps, promoting uptake of proven and effective interventions, and the coordination of local, provincial and national concussion work. She is the founder and chair of the BC Concussion Advisory Network, and participates on numerous provincial and national injury and concussion advisory committees. She has received both the BC Hockey Safety Award and the BC Hockey Service Award as well as the Brain Injury Association of Canada Prevention and Awareness Award.

Diagnosing

Concussion

Photo: Highwaystarz-Photography / iStock

FEATURE: DIAGNOSING CONCUSSION

Dr Fatima Nasrallah

HEAD INJURIES AND CONCUSSIONS ARE FORCING MORE AND MORE ATHLETES TO CUT SHORT OR TAKE A BREAK FROM THEIR SPORTING CAREERS. RESEARCH ON THE BRAINS OF FORMER ATHLETES IS RAISING AWARENESS OF THE LONG-TERM NEUROLOGICAL DAMAGE THAT CAN BE CAUSED BY REPEATED KNOCKS TO THE HEAD. BUT WHAT IF THERE WAS A BIOMARKER THAT COULD PINPOINT THE EFFECTS OF CONCUSSION ON THE BRAIN, AND MORE ACCURATELY INFORM CLINICAL MANAGEMENT?

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SECTION HEADER FEATURE: DIAGNOSING CONCUSSION

Diagnosing

Concussion

s our thirst for international sport grows, concussion is fast emerging as a major health issue of our time. Increasingly, more and more professional sports people are speaking up about their own personal experiences with the long-term effects of head injury. In younger people, the major cause of Traumatic Brain Injury (TBI) is motor vehicle accidents, followed by sporting injuries. There have been many studies on the effect of concussion in sport, both at a professional and amateur level, with major concern given to the long-term effects of repeated concussions leading to serious conditions such as Chronic Traumatic Encephalopathy (CTE). The impact of concussion and TBI has also been noted by the Australian Government, with $50 million invested over 10 years from 2019 in The Traumatic Brain Injury Mission, a research funding program aimed at improving patient recovery after brain injury. The key to understanding concussion is understanding how it affects the brain’s ability to function, and to what extent it puts players at a greater risk of recurring acute issues or developing brain diseases such as dementia. Understanding this is a major step towards early intervention, to prevent or reduce the likelihood of lasting damage. The Cause Concussion is broadly defined as the mildest form of Traumatic Brain Injury (TBI). Within the skull, the brain floats in a protected womb of cerebrospinal fluid. Concussion occurs when a direct impact or whiplash effect – either through a blow to the skull or the body — causes the brain to bruise from hitting the skull. Symptoms may include vomiting, fatigue and loss of consciousness. It is this loss of consciousness that experts now believe has led to the misdiagnosis of more serious concussions. Recent studies have shown that no loss of consciousness is associated with a two-fold risk of developing dementia. This is because athletes who suffer a knock to the head but display no outward loss of consciousness or symptoms are at a higher risk of developing long-term complications because they are more likely to return to activities before their brain has fully recovered. Their 30

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brain has undergone a major trauma and they’re being exposed to sub-concussive injuries that may be cumulative in causing long-term consequences. This tells us that the severity of the symptoms that you see at the time of the concussion is not related to long-term damage. Repeated concussion has been linked to increased risk of neurodegenerative conditions such as Alzheimer’s and Parkinson’s disease as well as Chronic Traumatic Encephalopathy (CTE). Currently, the only way to diagnose CTE is post-mortem which makes it impossible to catch the condition at an early stage.

FEATURE: DIAGNOSING CONCUSSION SECTION HEADER

According to the Australian Bureau of Statistics, almost 700,000 Australians live with a brain injury, with as many as two thirds of these suffering from the condition before the age of 25.

The Challenge One of the biggest challenges clinicians face is diagnosing concussion with many sporting bodies in Australia adopting an “If in doubt, sit them out” attitude towards treating potential concussions, as per the Concussion in Sport Australia guidelines. Visualising concussion-related changes in the brain is particularly difficult. Unlike the bleeding inside the brain that might occur with a severe head impact, no obvious structural changes accompany concussion. The severity of the concussion, the type of concussion that has occurred and the biological makeup of the individual, all need to be considered. Currently concussion is diagnosed with a clinical assessment to see whether a person is fit to go back to play using a SCAT5 test. This is the standardised tool for evaluating a suspected concussion. To some extent these tests measure cognitive ability, but they are mostly associated with observing the symptoms. Too often there is a mismatch between when the symptoms heal and when the brain heals. The symptoms might go away but the brain is still recovering from the bruising. In our recent paper published in Acta Neuropathalogica Communications, we showed that while the behavioural symptoms in animal models recovered, changes in the brain could still be detected by advanced neuroimaging, and these changes had not recovered even by day 14 post-concussion. We hypothesised that this could be easily translated to humans and assumed that the extent of changes and their progression would be evident in different individuals across different contact sports.

Photo: utah778 / iStock

Unlike conventional neuroimaging scans where mere pathology is only evident, advanced MRI offers the opportunity to look at details in the brain at the micro level. In our latest study, we are scanning athletes in high contact sports, using a 7 Tesla high magnetic field MRI scanner to elucidate some of the finer details in the brain. Our aim is to identify markers specific to the brain that can be easily monitored to distinguish whether there is a brain injury or when the brain has fully recovered. To monitor the trajectory of recovery, athletes involved in the study come in at specific time points before and after injury. They are first scanned prior to a concussion and then again at three, seven and 14 and 30 days to probe changes over time. VOLUME 39 • ISSUE 2 2022

FEATURE: DIAGNOSING CONCUSSION

Photo: Jolygon / iStock

Diagnosing

Concussion

Advanced magnetic resonance imaging (MRI) now offers us a unique window into the brain.

Using this probing method, researchers are using the advanced MRI to collect data on mild traumatic brain injuries to give certainty around when an athlete’s brain is fully recovered, and it is safe to resume play. To date, the study has involved more than 32 athletes including AFL and rugby players, fighters and kickboxers, all having a brain scan in the name of science and better athlete welfare. Preliminary results have shown that advanced neuroimaging has very high sensitivity to detect when the brain has recovered from a concussion and that recovery differs vastly from individual to individual.

Author Bio Dr Fatima Nasrallah is an Associate Professor at the Queensland Brain Institute

The Future To date, there has been lots of work done on blood and saliva biomarkers in concussion and yet none have made it to the clinic. We believe that by marrying advanced MRI with a blood or saliva biomarker, we can develop a point-of-care diagnostic that is not only quick and easy to use on the sidelines, but also provides unprecedented insight into the brain to protect athletes from the long-term consequences of concussion.

(QBI). She uses the full spectrum of imaging technologies to advance our understanding of what happens to the brain in the immediate aftermath of a concussion, as well as in the following weeks and months. Dr Nasrallah is now leading a large QBI study scanning athletes in high contact sports to identify a blood or saliva biomarker which could lead to a quick and easy to use point-of-care diagnostic which could be used on the sporting sidelines and in the clinic

There is still significant scope to develop clinically validated metrics that improve the accuracy of concussion diagnoses and the reliability of return-toplay decisions. We are still a long way off gold standard clinical management, but the future looks promising. 32

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to help inform injury progression and ultimately return to play decisions

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OCTOBER 2022

2022 SMA CONFERENCE

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Visit ccthpc.com.au or email ceo@cowboys.com.au VOLUME 39 • ISSUE 2 2022

VOLUME 25 ISSUE 2 FEBRUARY 2022

IN THIS ISSUE: • Elite athletes maintain peak performance after testing positive for SARS-CoV-2. • Exercise and Sports Science Australia (ESSA) position statement on exercise for people with mild to moderate multiple sclerosis. • What did the ankle say to the knee? Estimating knee dynamics during landing a systematic review and meta-analysis.

SPORTS & EXERCISE MEDICINE SPORTS INJURY PHYSICAL ACTIVITY SPORTS & EXERCISE SCIENCE

5 MINUTES WITH SECTION HEADER

5 minutes with

Andrew J Gardner How and when did you start working in sports medicine? So, I am a clinical neuropsychologist. I’m not a medical doctor but I have been working in sports medicine in the context of being a concussion researcher and clinician from around 2002, which was the first time I ever did a research project. My own research I started to develop from about 2012 onwards. What inspired you to get into this area? Well, I was fascinated by how the brain works and I am also a really big sports fan. I wanted to try and merge my fascination with the brain and my love of sport together. Neuropsychology and sports concussion became kind of my area of passion and interest. Can you give me a bit of background on your education? What you studied and how that got you to where you are now? I started out doing an undergraduate degree in psychology at the University of New England in Albany and in my third year of undergraduate studies, I had a professor who was running a research program with the local boys rugby union school in Tasmania. We were looking at computerised cognitive testing and managing concussions, so I got a bit of a taste of that then. Once I completed my undergraduate studies I moved to Sydney, went to Macquarie University and completed a Postgraduate Doctoral of Clinical Neuropsychology. My research was looking at concussion in rugby union. I then moved to Newcastle and started working as a clinician independently whilst also completing a PhD looking at the long-term consequences of concussion for rugby players. You’ve worked with the World Rugby on Concussion Policy as well as SMA’s concussion policy. Could you tell me a bit about that process? I am the concussion consultant for Rugby Australia. So, I’ve done a lot of work looking at rugby union and rugby union players. I had the opportunity to join the World Rugby Concussion Working Group and in my role with Rugby Australia, we have been working on policy development and implementation at the grassroots level right through to the professional level. I first became involved with Sports Medicine Australia when the concussion policy was created in 2018. It was developed by a combination of Dr. David Hughes, the Chief Medical Officer of the AIS, and the Chief Medical Officers of a few of the contact and collision sports. I also went out and did all the education throughout New South

Wales, community education and medical education, promoting the policy and the development of that as well. Do you have any key personal or career goals? I’ve led a research program in the area of long-term brain health in contact and collision sports athletes for the last eight years, and we are now moving into the next phase where we are encouraging or trying to recruit people from all sports, including both men and women athletes, to have a look at how their brain health is going and trying to help with that. How has being a part of Sports Medicine Australia helped your career and research? It’s a fantastic network of multidisciplinary professionals who give me not only a great opportunity to spread the work that I’m doing, but also learn from others. It’s certainly very beneficial and helpful. VOLUME 39 • ISSUE 2 2022

PEOPLE WHO SHAPED SMA: K AY COPEL AND

People Who Shaped SMA

Kay Copeland What’s a bit of your educational background? Where did you study when you came back to do physio? I have studied everywhere. My initial human movement was at FIT (now Victoria University). In the USA I attended Indiana State University for my Masters in Athletic Training (and my thesis) and then physiotherapy at Lincoln School of Health Sciences, which is now LaTrobe University. I recently studied again and am now a Specialist Sports and Exercise Physiotherapist, after I successfully passed the exams under the Australian College of Physiotherapy in 2018.

What made you decide to pursue a career in sports medicine? I originally did human movement and didn’t want to teach, so I went to the USA and completed a Masters in Athletic Training and successfully passed the national exams to be an Athletic Trainer Certified in the USA. Once I did that, I knew that was the area I wanted to work in. But when I came home to Australia, I was the only person who had ever done that qualification. So, I went back to university again and completed physiotherapy. I had played team sports all my life and always had a love of sports – so combining all of this learning from 3 degrees with my love of sport, made it quite easy to know that sports medicine was a good fit for me. 36

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Can you tell us a bit about the work you have done on SMA Conference? I became Conference Chair in 2011. I went through a year’s mentorship under the very experienced previous chairs of Dr Anita Green, Professor Jill Cook and Dr Wendy Brown. The first conference I chaired was a conference in Perth, and I was Conference Chair for seven years with a wonderful committee of SMA members. What is a career highlight for you? What is something that you have done that is particularly important or that you are particularly proud of in your career in sports medicine? I was the Program Manager for the Medical Program at the 2006 Melbourne Commonwealth Games. I had 25 staff and over 500 volunteers that we placed for that event. It ran for 21 days, over 72 venues that all had

medical rooms and the large-scale polyclinic at the Commonwealth Games Village. What I was particularly proud of is the way that we structured our services. We implemented a brandnew program, where we put Australian leading sports physiotherapists into incoming teams to provide services that had never been done before. Because of the quality of Australian sports physiotherapists, we felt that was an appropriate and a wonderful program that helped all the incoming athletes. We increased the role of sports medicine at every venue and tried to make it proactive and get people ready and look after them when they are injured. We also increased the doping control program by providing an educational program throughout the incoming countries by putting out anti-doping education before the event started. Can you tell me how you got initially involved with some of the sporting organizations such as the Australian women’s basketball team and the Australian Women’s Water Polo Team? I played Water Polo since I was ten years old and have a lifelong involvement with the sport. Both of my sisters represented Australia and I was in America studying athletic training when my sister was in the Australian team traveling over there. I went and met them for that tour and provided sports medicine services as an athletic trainer to them and continued to provide those services for many years.

PEOPLE WHO SHAPED SMA: K AY COPEL AND

When you get an opportunity to start, do it, it may not be the sport you want, it may not be the level you want, but you should get involved because you begin to learn what sports medicine is. I was the first person to do this for the Australian Women’s Water Polo Team. During this period, the team won the World Championship in 1986 in Madrid – the first world championships ever conducted for women’s water polo. I have been involved in Water Polo my whole life. I am involved in a club in Melbourne, and I am a Board Member of Water Polo Australia. I worked internationally for over 10 years with the Women’s Tennis Association (WTA) as an independent contractor at tennis tournaments all around the world. I didn’t have a background in tennis, but because I was a physiotherapist who was also an athletic trainer, I was able to get involved in the very early days. This was quite a unique world of elite women’s tennis and took me all around the world and worked with sports medicine professionals from all over the world. I worked for an NBL team when I first returned to Australia from studying in the USA. I did this for a number of years and because of the relationships I had developed I returned to work for the Australian Women’s Basketball program for 3 years as one of the physiotherapists providing services. Again, an amazing experience to work with elite women athletes. How has being part of SMA helped your career in sports medicine? Sports Medicine Australia has continued to, throughout my entire

career, provide me with opportunities to network, know people and work with people that would never have become available to me in any other way. The more things I do with Sports Medicine Australia, the more people I meet, know, engage with, learn from, help and grow my personal network. Do you have any advice for people starting out in sports medicine and trying to make their way in the industry? My advice is that you have to start somewhere. When you get an opportunity to start, do it, it may not be the sport you want, it may not be the level you want, but you should get involved because you begin to learn what sports medicine is. Working in a clinic type setting is wonderful, but I think most sports medicine practitioners would say being involved in the sport environment as a service provider, actually on site, is a huge learning opportunity to get a wider view of what the sports medicine industry is. Jump in and get started, don’t worry about what that is, see if you like the type of work, see if your personality fits. If you start, opportunities will come, especially if you are good, love it, talk to people, grow your network. You will slowly move into different opportunities, different areas, and you may end up in the thing you thought you dreamed about, but you may end up in something totally different that you love even more.

How did you get involved in SMA? When I returned to Australia in 1985 as an Athletic Trainer, I was already a member of SMA (ASMF as it was known then). I was asked to, and did, join the Victorian Branch Sports Trainers Committee that was being formed. This Committee was amazing, led by Dr Frank Archer and included current ASMF Order of Fellows President Michael Kenihan. The Committee grew the sports trainers program to such a degree that I was employed in 1987 to work 8 hours a week to administer the program. At the same time the committee set about writing the first ever standardised texts for the sports trainers courses. I worked for Victorian Branch from 1987 to 2004 in many roles. I was predominantly the Manager of the sports trainers program – which grew to putting over 1500 people/year through the courses ran throughout Victoria. In later 1990’s I became Executive Officer of the Victorian Branch until 2004. Through the years I have worked for SMA, been on committees, Conference Chair and now currently sit on the Board as the Deputy Chair. Throughout that time, I have always been amazed at the willingness of our community in sports medicine and sports science to work together and grow the area for all that are involved. All SMA events have a strong learning aspect, but it is often the networking and social elements that sets SMA apart from many other organisations. VOLUME 39 • ISSUE 2 2022

SPORTS MEDICINE AROUND THE WORLD: HUNGARY

Sports Medicine

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SPORTS MEDICINE AROUND THE WORLD: HUNGARY

e in Hungary Photo: ZoltanGabor/iStock

MEDICINE IS EDUCATED IN FOUR MEDICAL SCHOOLS IN HUNGARY: BUDAPEST, SZEGED, DEBRECEN AND PÉCS. THE LANGUAGE IS NATURALLY HUNGARIAN, BUT THERE IS EDUCATION AVAILABLE IN ENGLISH AND GERMAN LANGUAGES FOR FOREIGN STUDENTS.

t each Medical University (Budapest, Szeged, etc.), Sports Medicine departments have been established.

In medical education, Hungary does not follow the Bologna principles – it has no bachelor or master levels. Normally, medical studies last six years and the last year is clinical practice. The 12 months are divided into one to three-month periods of internal medicine, surgery, paediatrics, neurology and psychiatry. At the end of the studies, students must present a diploma work and give a state examination, with the help of which, they will be General Practitioners without any specifications, and they are authorised to use the ‘Dr’ title. Usually, all physicians use it. After this, they can start their medical career and work in the field of their chosen medical specification. There is a system to be a resident in some medical specifications, helping to reach the qualification. From the 2020-21 academic year at the Semmelweis University, Budapest, a one week Sports Medicine practical curriculum was introduced as a mandatory course, with final exams, for fifth year medical students, including foreign language (German and English) students.

Sports Medicine has been a sub-specialty in Hungary since 1999. Before this date, sports medicine was an independent specialty with four years of education (for about 40 years) but you had the opportunity to complete it in two years as well, in case you had a specialty like orthopedic surgeon or something similar. The current requirements of the two year preparation are as follows: ٚ Any kind of primary medical specialisation (GP, paediatrician, etc.) ٚ Internal Medicine: two months ٚ Cardiology or Emergency Cardiology: six weeks ٚ Orthopaedic Surgery, Traumatology or Sports Surgery: two months ٚ Rehabilitation and Physiotherapy: six weeks ٚ Exercise Physiology: two months The abovementioned practices could be fulfilled only at accredited departments of hospitals or university institutions. ٚ Sports Medicine practice: 12 months in any outpatient department of Sports Physician Network, which is under the responsibility of the Hungarian Institute for Sports Medicine, Budapest. The other possibility is to work with an elite national team as a Team Physician. ٚ Mandatory courses: two week basic sports medicine course organised VOLUME 39 • ISSUE 2 2022

SPORTS MEDICINE AROUND THE WORLD: HUNGARY

Sports Medicine in Hungary by the Hungarian Instititute of Sports Medicine or Sports Medicine Department of Universities. ٚ Oxyology: one week ٚ Mandatory consultation in the Hungarian Instititute of Sports Medicine: 4x2 weeks ٚ Administrative issues: Once you decide to become a sports physician, you have to prepare a two year plan for different practices (where, when, etc). An Official Board should approve and you will get a mentor. If you fulfill all the mandatory practices (you need written documentation) you can enter for the final examination. The certificates of your practices and courses must be accepted by the Official Board. The exam includes a one day practical and a one day theoretical led by a Board of Examination. Generally, the Board includes an Exercise Physiologist, an Orthopaedic Surgeon, an Internist, and the Chair. All of them are Sports Physicians.

In Hungary, there are approximately 200 medical doctors with sports-specific qualifications and nearly 150-160 of them are actually working in the network of the Hungarian Sports Physician Network (sports medical consulting rooms, doctors of sports clubs or of the national teams).

Sports medical doctors are authorised to work in any level of sports. A usual practice is that physicians of the national teams and top-level sports clubs should be specified sports doctors. This principle cannot always be followed perfectly as we do not have enough sports medical doctors.

consulting rooms, doctors of sports clubs or of the national teams).

In Hungary, there are approximately 200 medical doctors with sportsspecific qualifications and nearly 150-160 of them are actually working in the network of the Hungarian Sports Physician Network (sports medical

September 2021, Budapest

As usual, in Hungary, qualifications are valid for five years. During this period, it is necessary to collect some credits from special courses, scientific congresses and publications.

Prof. Dr. Éva Martos Past President of the Hungarian Society for Sports Medicine

Author Bio Professor Éva Martos M.D. PhD, is the professional Head of the Center of Sports Nutrition Science at the University of Physical Education in Budapest, Hungary. She is a specialist in Clinical Laboratory and in Sports Medicine as well. She spent 25 years at the National Institute for Sports Medicine, then she led the National Institute for Food and Nutrition Science for 10 years. She was the team physician of the national female gymnastic team and also of the swimming team. She participated at three Olympic Games, being the Chief Medical Officer in the Sydney 2000 Summer Olympic Games. She was a member of the Executive Committee of the European Society of Sports Medicine (1997-2005), the Chair of the Scientific Committee of FIMS (1997-2002), the WHO Nutrition Counterpart for Hungary (2005-2016) and the EU DG Sanco High Level Group on Diet and Physical Activity (2007-2016). Professor Martos has got extensive teaching experience in different subjects. She has been contributing to the Hungarian Review of Sports Medicine as the chairwomen of the Editorial Board. She was the president of the the Hungarian Society for Sports Medicine between 2015-2018. Professor Martos organised several national and international congresses (for example, the XXVII FIMS World Congress in 2002, and Hungarian EU Presidency Conference “Action for prevention” in 2011). She is now the president responsible for organising the EFSMA 2022 Congress which is going to be held in Budapest, Hungary.

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SPORTS TRAINER HIGHLIGHT

Sports Trainer Highlight with

Patrick Moase How did you first get involved with Sports Medicine Australia? The first time I got involved with SMA was when I did my Level 2 Sports Trainer course and I did a fair bit of work with the local Broom Jets Rugby League Club and also with NRLWA. I also had various representative opportunities including last year where I was the senior women’s Head Trainer. Because of COVID-19, it was a little bit difficult for SMA to facilitate courses remotely and throughout the country. I got approached by SMA to ask if I’d be interested in facilitating a Broom Level 1 Sports Trainer’s course. So, they did not need to worry about trying to send up or send across facilitators from the state or from Perth. How long have you been a Sports Trainer for? What was the start of your Sports Trainer journey? I did my Level 1 Sports Trainer course with SMA in 2018 and I really enjoyed it and noticed that there was a need for people with experience in concussion management and management of initial injuries on the field and a lack of that in the area that we were in regionally. So, I fairly quickly built up enough hours to do my Level 2 and jumped straight into that and then continued to get a lot of on the field training, I also volunteered for opportunities where I was able to improve my knowledge a bit more and undertake more courses and became a member of SMA. What do you enjoy most about being a Sports Trainer? What’s something that is special about it for you? I think the biggest reward is parents, players and onlookers getting comfort

that there’s a presence of people that have the welfare of players as their focus and that’s what being a Sports Trainer feels like. We contribute the most to the sport. We are not interested in the results of the game or what was being played. It’s more about players, irrespective of their age, who come into the game and their welfare is taken care of. Whether that’s recommendation to seek further advice for injury management or just the comfort of having people being there that can alleviate coaches’ interpretations of whether players are able to continue or not continue in the game or sports due to an injury.

Do you have any advice or tips for any Sports Trainers who might be starting out in this field? One of the best tips I can give Sports Trainers and I didn’t have the luxury of this opportunity, was to develop a relationship with other Sports Trainers. This is where you can work and help each other together and leverage off their knowledge and impart your knowledge. Because it’s very difficult to do the course and then not really transition on to the field in a role without guidance. So, I think developing a network is probably my best advice.

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Publisher Sports Medicine Australia PO Box 78 Mitchell ACT 2911 sma.org.au ISSN No. 1032-5662 PP No. 226480/00028